The authors have not supplied their declaration of competing interest.

Teaching, as a profession, is recognized as demanding and stressful.

(1) Evaluate the professional teacher stress, (2) Identify possible factors associated with it.

This is a cross-sectional study, descriptive and analytical, conducted among teachers of high school Mahmoud Magdich in Sfax. (Tunisia). Participants were asked to complete the anonymous form detailing the socio-demographic, professional characteristics and any work stressors.

The evaluation of occupational stress was evaluated by the scale of “Karasek”.

Thirty-six teachers replied to the questionnaires. The sex ratio (M/F) was 0.38. The mean age was 48.77 years. The average number of years of exercise was 23.20 years and the average number of hours worked per week was 16.25 hours. The participants stress profile according to the scale of “Karasek” was: 55.6% stressed, 27.8%, assets, 11.1% liabilities, and 5.6% relaxed. The main stress factors mentioned were respectively: the inadequate salary (58.3%), difficult working conditions (52.8%), problems with students and parents (25%) and lack of organization at work (22.2%). Factors correlated with the profile “stressed” were: female gender (P = 0.026), lack of pastime practice (P = 0.034), teaching high school degree (P = 0.04), feeling that they work “too hard” in their work (P = 0.005), they are “the end” at the end of the working day (P = 0.015) and low social support (P = 0.005).

The occupational stress among teachers was quite important. Knowing how to identify factors and taking action would be interesting for the guarantee development for teachers. Students would be the ultimate beneficiaries.

The authors have not supplied their declaration of competing interest.

Somatoform disorders are a therapeutic challenge for primary care physicians. Various studies show low efficacy of psychotherapy for these patients, and the need for differentiated approach to their treatment.

Explore the differences between pathopsychological, personal characteristics of patients with somatoform disorders.

It was carried out psychometric evaluation of 108 patients with different clinical variants of somatoform disorders, using SCL-90-r, Leonhard questionnaire.

Patient with somatization disorder (SD) had maximum values on the “somatization”, “depression”, “hostile”, “paranoid” scales; a high level of anxiety. Singularity personality structure of these patients defining feature of exaltation, excitability, emotivity. Patients with undifferentiated somatoform disorder (USD) also showed high levels of somatization, anxiety and obsessive-compulsive, interpersonal sensitivity, phobic anxiety. Patients with stable somatoform pain disorder (SPD), had high levels of depression, obsessive-compulsive. SPD formed in individuals with features of anxiety, seizing, high emotivity. The maximum values for the scales of anxiety (ANX, PHOB) recorded in patients with somatoform dysfunction of the autonomic nervous system (SDANS). Evaluation of coping strategies showed a preferential use of the “avoidance” strategy by patients with SD, USD, a rare use of social support strategies, responsibility. Patients with somatoform pain disorder often resorted to seek social support.

The use of the questionnaire SCL-90-r has identified a number of clinical features of patients with different variants of the SFD. Typologically in all samples of patients revealed moderate accentuation on emotivity trait.

The authors have not supplied their declaration of competing interest.

Although a certain level of competitive anxiety may increase performance, many athletes with anxiety experience uncontrolled negative feelings and cognition that in turn can have overwhelming effects on their performance.

Indeed, we aimed to assess the effect of the acupuncture on competitive anxiety in a sample of young football players using physiological biomarkers and subjective anxiety measures.

We aimed to assess the effect of acupuncture on competitive anxiety of the adolescent football players prior to the competition using psychological and physiological markers. A total of 30 athletes were randomly and equally allocated to either acupuncture or sham control group.

The results of t-test on posttest scores showed that acupuncture had a significant effect on cognitive anxiety (P = 0.001) and somatic anxiety (P < 0.001) but not self-confidence (P > 0.05). Furthermore, the results showed that acupuncture significantly decreased the skin conductance in acupuncture group compared to sham group (P = 0.006) (P < 0.001).

In conclusion, the results suggested that acupuncture have the capacity to decrease cognitive and somatic anxiety prior to competition in adolescent athletes while this was accompanied by significant physiological changes.

The authors have not supplied their declaration of competing interest.

Stigmatization of individuals with mental illnesses is widespread and serves as a major barrier to treatment. Specific alterations in mental health literacy about a disorder and its perceived treatability can change this social attitude. Assessing awareness of bipolar disorder is important as the WHO ranked bipolar disorder as the sixth cause of disability.

To assess mental health literacy (knowledge, attitudes and beliefs) in bipolar disorder among Saudi population.

Cross sectional study is currently conducted. We are using valid reliable questionnaire assessing the level of awareness, knowledge, attitude and behavior toward bipolar disorder. It is distributed to adult Saudi citizen (> 17 years of age) in malls, university and hospitals in Riyadh. People who are known to have psychiatric disorder and their caregivers or who works as psychiatrists and psychologists are excluded.

There are 200 samples collected, and 14 were excluded according to exclusion criteria. Fifty-two percent of our preliminary sample has heard about bipolar disorder, and more than half of them believe that neurotransmitter disturbances, substance use and psychological trauma are more likely to be causes of bipolar. In contrast, 49% of the sample did not choose psychiatric medication as effective treatment for bipolar, whereas more than half of them chose praying.

It is a first-of-its-kind research study in Saudi Arabia determining the current mental health literacy of bipolar disorder in Saudi Arabia. We are aiming to increase the sample size to reach 1000 participants. Further study will be needed to investigate possible interventions to improve such problem.

The authors have not supplied their declaration of competing interest.

Ample amount of data suggests role of REM sleep deprivation as the cause and effect of mania. In the present model, we have tried to implement behavioral sensitization to sleep deprivation, conditions mimicking natural circumstances, so as to produce an animal model with symptomatology resembling very close to human mania. Pre-clinical and clinical studies have shown that mania is often co-morbid with multiple sclerosis, therefore we sought to find out whether myelin integrity is disrupted and if lithium could protect against such damage.

(1) To analyse mania-like behavior after REM sleep deprivation. (2) To analyse any damage to myelin under TEM.

We wanted to see if there could be any damage to myelin after behavioral sensitization to stress.

Rats were sleep deprived by classical flowerpot or platform method. OFT was performed to assess behavior of rats. The analysis was performed over 5 min, separated into 5 bins of 1 min each. Behavioral scores included total square entries, inner square entries, time spent in center, rearing frequency, time spent rearing, number of grooming bouts, time spent grooming defecation and time spent still. TEM was performed to study changes in myelination in two distinct regions of brain, DG and VTA.

It was observed that the REM sleep deprived rats had mania like symptoms. REM sleep deprivation lead to demyelination in DG and VTA. Lithium treatment restored myelination per se.

The result suggests the involvement of myelin damage in the pathogenesis of mania, Li offers protection against such damage.

The authors have not supplied their declaration of competing interest.

Sodium valproate can cause serious developmental disorders in unborn babies if taken while pregnant, especially in the first trimester.

To review recent literature and advice or treatment for women who have or are using valproate whilst pregnant.

Literature review.

Literature review using Pubmed with search terms: ‘bipolar’; ‘pregnant’; ‘valproate’ and following up references.

There are several small methodologically flawed studies that attempt to address this question and will be reprised. Three key population register studies found high rates of malformations. A retrospective study of longer-term outcomes found high rates of developmental issues. There are several relevant treatment guidelines, including from the National Institute for Health and Clinical Excellence (NICE). There is a 40% risk of developmental disorder, a 10% risk of congenital malformations and a 3% risk of IQ deterioration.

Avoid valproate in women of childbearing age if at all possible, and consider effective contraception if used. If already pregnant then consider, with involvement from the patient, stopping or minimizing the dose of sodium valproate. Assess the risks and benefits of using sodium valproate during pregnancy versus stopping the treatment for the first trimester as symptoms of the disorder may return. Seek advice from a perinatal psychiatrist. Add 5 mg of folic acid daily for the remainder of the pregnancy.

The authors have not supplied their declaration of competing interest.

Bipolar disorder is a disabling condition characterized by the presence of manic, depressive, hypomanic or mixed episodes, affective symptoms that may coexist with several types of psychotic features.

The purpose is to evaluate the frequency of psychotic symptoms among bipolar disorder.

The study included 55 bipolar patients admitted in the Psychiatry Clinical Hospital from January 2012 until May 2013. Inclusion criteria were represented by diagnosis of bipolar disorder, manic or depressive episode, according to DSM-IV-TR and ICD 10 criteria. Clinical instruments used to assess the severity of the current affective episode were Young Mania Rating Scale (YMRS) for manic patients and Hamilton Depression Rating Scale-17 items – (HDRS) for the depressive ones. Psychotic symptoms were evaluated with the Brief Psychiatric Rating Scale-18 items – (BPRS).

Out of the 55 patients, 32 had psychotic symptoms upon admission to the hospital. BPRS results showed delusions of guilt, inutility, hypochondriac and nihilistic delusions for the depressed patients. Delusions of grandiosity and megalomania accounted for most of psychotic symptoms in manic patients. A smaller number of patients showed delusions of invention and reform. Perception disturbances such as auditory hallucinations were present in both diagnosis categories but in a higher percentage in depressive bipolar patients.

Even if less frequently than in schizophrenia or schizoaffective disorder, psychotic symptoms are present in bipolar disorder. They influence the general functioning and the outcome of patients diagnosed with this illness.

The authors have not supplied their declaration of competing interest.

Depression is one of major health problems affecting pregnant women in low resource settings. It can lead to poor uptake of antenatal services. Data about prevalence of antenatal depression and associated risk factors remain scanty in Malawi. The study settings were eight selected antenatal clinics in Blantyre district, Malawi. The aim of this study was to assess prevalence of antenatal depression and associated risk factors among pregnant women attending antenatal clinics in Blantyre district, Malawi.

This was a quantitative study which used a random sample of 97 pregnant women. Ethical approval was granted by relevant bodies. Descriptive and inferential statistics were used to analyse data.

Prevalence of antenatal depression in Blantyre district was 25.8% (n = 25). Risk factors associated with antenatal depression included: “being distressed by anxiety or depression for more than two weeks during this pregnancy”; “feeling that pregnancy has been a positive experience”; “having a history of feeling miserable or depressed for two weeks or more before this pregnancy”; “relationship with partner is an emotionally supportive one”; “experiencing major stresses, changes or losses in the course of this pregnancy”; “having history of physical abuse when growing up”, and “having concerns about being or becoming a mother”.

This study has shown that antenatal depression is prevalent in Malawi. It suggests that psychosocial interventions targeting pregnant women may be necessary to reduce antenatal depression and associated risk factors. However, further research regarding ways for assisting pregnant women to build and strengthen their psychosocial support structures is needed.

The authors have not supplied their declaration of competing interest.

Several studies have shown that ketamine, an antagonist of NMDA receptors, represents a promising alternative in the treatment of depression. The therapeutic use of ketamine, commonly used at a dose of 0.5 mg/kg, and in a single application IV has been short and requires monitoring in a hospital setting. IM use has been shown to be effective in treating depression and suicide risk, and have low side effect profile.

Two patients diagnosed with bipolar depression and suicide risk were submitted to ketamine IM application (0.75 mg/kg), receiving one application of ketamine IM every two days, totaling 4 applications. Patients were under medical monitoring for 2 hours after injection verifying vital signs and potential side effects. Responses were measured using BDI, BAI and BSI.

To evaluate response of ketamine IM injections on depressive, suicidal and anxious symptoms.

Case 1: female, 20 years old, single with three recent suicide attempts, symptomatic for two months. Started lithium 450 mg daily. Side effects of ketamine were nausea, drowsiness and paresthesia. Case 2: female, 24 years old, single with symptoms lasting for six years. Started aripiprazole 5–10 mg and 25 mg lamotrigine concomitantly. Side effects of dry mouth, dizziness and dissociation.

The use of ketamine IM showed reduction of 75.5%–83.3%–85.7% (case 1) and 71.4%–77.2%–60.8% (case 2) in BDI, BAI and BSI, respectively as well as safety and tolerability in use.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

The Psychiatry Clinic Affektiva has developed a care pathway for patients with bipolar disorder (BD). It consists of one outpatient clinic and two inpatient wards. Clinical observations suggest that patients with BD benefit from treatment in a dedicated unit with tailored care programs and that better outcomes are achieved in terms of reduced average length of stay and safer transitions to outpatient care for this group.

The aim is to improve the care of bipolar patients by increasing bed-availability and overall continuity in the care pathway and monitoring core aspects in the management of outpatients in order to reduce admissions and to facilitate standardized treatment and collaboration between in- and outpatients unit.

We developed a structure to monitor and measure specific outcomes such as readmission within 28 days, relapse within 12 months and the use of lithium in this group. We also developed a standardized care protocol in order to improve the safety and the equality.

At this stage our preliminary results from our efforts are promising but further monitoring is needed to confirm our hypothesis. More data will be collected during 2017.

Affektiva Psychiatry Clinic has developed a model for continuously monitoring several essential aspects in the care of patients with BD and providing a specific care program.

The authors have not supplied their declaration of competing interest.

Suicide behaviors (suicide acts and suicide attempts) are a major concern for clinicians treating patients with psychiatric disorders. Among them, patients with bipolar disorder (BD) have the highest prevalence of suicide behaviors, accounting for up to one-quarter of all completed suicides. Additionally, suicide remains the leading cause of avoidable death in patients with BD.

This work aims to review the main risk factors for suicide behaviors in patients with BD.

The MEDLINE/Pubmed database was searched using the keywords “bipolar disorder” with: “suicide”; “suicide attempt”; and “suicide risk factors”. Articles published in the last 10 years were considered.

It is estimated that 25% to 50% of patients with BD will attempt suicide at least once in their lifetime and, that 10% to 15% will die. The risk factors for suicide behaviors in patients with BD have been widely studied and their knowledge is crucial for identifying patients at risk.

The main risk factors include previous suicide attempts, family history of suicide and hopelessness. Other risk factors have also been identified: depressive polarity of first mood episode; rapid cycling; increasing severity of affective episodes; depressive polarity of the latest mood episode; mixed affective states; early age of onset; and comorbid anxiety disorders, substance use disorders and cluster B personality disorders.

Prevention of suicide behaviors is crucial when treating patients with BD. Therefore, the knowledge of these risk factors is of extreme importance in order to promptly identify patients at risk and adopt the proper preventive therapeutic interventions.

The authors have not supplied their declaration of competing interest.

Mindfulness-based cognitive therapy (MBCT) is a psychotherapeutic intervention that has been shown effective in several clinical conditions. Nevertheless, research is still needed on its effectiveness on cognition.

To analyze possible effects on cognition of the addition of MBCT intervention versus a brief structured group psycho-education to the standard treatment of subsyndromal bipolar depression. Our hypothesis was that MBCT could improve some aspects of cognitive function to a higher degree than psycho-education and treatment as usual (TAU).

A randomized, multicenter, prospective, versus active comparator, evaluator-blinded clinical trial was conducted. Forty patients with BD and subclinical or mild depressive symptoms were randomly allocated to:

– MBCT added to psychopharmacological treatment (n = 16);

– a brief structured group psycho-educational intervention added to psychopharmacological treatment (n = 17);

– standard clinical management, including psychopharmacological treatment (n = 7).

Assessments were conducted at screening, baseline, post-intervention (8 weeks) and 4-month follow-up.

Cognition results point to significant improvement in Stroop Color test as well as processing speed in TMT A test (P < 0.05) in the two psychological intervention groups versus TAU.

These preliminary findings suggest that the addition of MBCT or psycho-education to usual treatment could improve some cognitive dimensions in subsyndromal bipolar depressive patients.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Late-onset bipolar-illness (LOBI) diagnosis comprises those patients whose first mania episode occurs aged 60 or older. Traditionally, it has been considered as a secondary disorder, accompanying other conditions such as dementia. While this is true for some cases, LOBI is a wider concept, which has its own features and also includes other entities.

To describe the main features of LOBI.

Critical review of the literature and description of the case of a 72-year-old woman diagnosed with LOBI.

While only 6–8% of all new cases of bipolar disorder (BD) occur in people older than 60, recent research suggests an increase of first episodes in this age group. LOBI is less associated with family history compared to early onset BD and seems to occur more frequently in women.

LOBI presents with better premorbid functioning and atypical psychopathology as compared to early onset. Also, there is a higher prevalence of mixed episodes and a higher frequency of episodes per year, with a great risk of suicide. LOBI patients have more cognitive impairment and higher rates of comorbid psychiatric disorders.

These patients show some specific neuroimaging signs, including subcortical hyperintensities.

Quetiapine and valproate have proved useful, but the pharmacokinetic and pharmacodynamic characteristics of older patients must be taken into account.

The reported case identifies similarities between LOBI and classical BD. However, both this case and the literature review reveal that LOBI has specific features that differentiate it from classical BD. Further research is needed to characterise the condition and improve its management.

The authors have not supplied their declaration of competing interest.

Clinical evidences suggests that cerebral inflammatory processes are involved in the development of major affective disorders [1].

Obvious correlations exist between changes of inflammatory markers such as acute-phase protein C (PCR) and VES, in patients with bipolar spectrum diagnosis [2].

Our aim is demonstrating the correlations between changes of PCR and VES and pharmacological treatment with atypical antipsychotics in patients with acute bipolar disorder, highlighting a trend.

Twenty patients with bipolar disorder were assessed at the entrance (T0), after three weeks (T1) and after six weeks (T2) of hospitalization using specific rating scales and blood tests routines include PCR and VES.

Is possible to appreciate a correlation between the affective phase of bipolar disorder and inflammatory markers with a proportional trend (Table 1).

The scores obtained seem to confirm the effect of antipsychotic in both sense of psychiatric symptomatology reduction and in anti-inflammatory action.

A confirmation of a correlation between the resolution of affective disorders and normalization of inflammatory markers confirm the intrinsic anti-inflammatory activity of such drug compounds [3].

The authors have not supplied their declaration of competing interest.

Within the various cultures and throughout the centuries has observed the relationship between emotional states and heart function, colloquially calling him “heartbroken”. Also in the medical literature are references to cardiac alterations induced by stress.

Takotsubo is a rare cardiac syndrome that occurs most frequently in postmenopausal women after an acute episode of severe physical or emotional stress. In the text that concerns us, we describe a case related to an exacerbation of psychiatric illness, an episode maniform.

Woman 71 years old with a history of bipolar I disorder diagnosed at age 20. Throughout her life, she suffered several depressive episodes as both manic episodes with psychotic symptoms. Carbamazepine treatment performed and venlafaxine. He previously performed treatment with lithium, which had to be suspended due to the impact on thyroid hormones and renal function, and is currently in pre-dialysis situation.

She requires significant adjustment treatment, not only removal of antidepressants, but introduction of high doses of antipsychotic and mood stabilizer change of partial responders. In the transcurso income, abrupt change in the physical condition of the patient suffers loss of consciousness, respiratory distress, drop in blood pressure, confusion, making involving several specialists. EEG was performed with abnormal activity, cranial CT, where no changes were observed, and after finally being Echocardiography and coronary angiography performed when diagnosed Takotsubo.

In this case and with the available literature, we can conclude that the state of acute mania should be added to the list of psychosocial/stressors that can trigger this condition.

The authors have not supplied their declaration of competing interest.

The diagnosis of major depressive disorder (MDD) is symptom based due to the lack of biological biomarker. p11 protein was recently found to be an important factor mediating depression-like states and antidepressant responses. The aim of the study was to assess whether p11 protein in urine can serve as a potential biomarker for major depression, and the relationship of its levels among urine, serum and cerebrospinal fluid (CSF).

We obtained urine samples from 13 drug-free MDD patients and 13 age- and gender-matched healthy controls. We also collected urine, serum and cerebrospinal fluid samples from 13 of fracture patients or cesarean section patients in the spinal anesthesia. The concentrations of p11 protein were measured using ELISA.

In MDD patients, urine levels of p11 protein were all less than the minimum detectable concentration of the ELISA kit. The urine levels of p11 were detectable only in one healthy control. In the spinal anesthesia patients, we can detect p11 concentrations in both serum and urine in only two patients. Besides, levels of p11 were detectable in the serum of one patient and urine of another patient. We were unable to measure CSF levels of p11 in all patients.

Concentrations of p11 protein in the body fluids are very low and unstable. The sensitivity of the current p11 ELISA kit is currently unsatisfactory, requiring the development of an ELISA kit of higher sensitivity to determine whether p11 in body fluids can serve as biomarker for depression.

The authors have not supplied their declaration of competing interest.

Many guidelines for bipolar disorders have been introduced based on evidences. In contrast, KMAP-BP was developed by an expert-consensus.

To summarize the medication strategies for bipolar depression over four published KMAP-BP (2002, 2006, 2010, and 2014).

The questionnaire using a nine-point scale had covered some clinical situations with many treatment options about the appropriateness of treatment.

For mild-to-moderate depression, antidepressant (AD) + mood stabilizer (MS) in early editions and MS or lamotrigine monotherapy and AAP + (MS or lamotrigine) in later editions were preferred strategies. For severe nonpsychotic depression, MS + AD was the only first-line medication in early editions. In 2014, various medications [MS + AAP (atypical antipsychotic), AAP + lamotrigine, MS + AD] were preferred. Valproate and lithium has been rated as first-line MS in all editions. Lamotrigine were positively preferred later. Adjunctive AD was accepted as first-line strategy for severe depression in all editions. Preference of AAP also has been increased remarkably. Adjunctive AAP was not first-line treatment for mild-to-moderate depression in all editions, but was for nonpsychotic depression in 2010 and 2014 and for psychotic depression in all editions. Recommended AAPs have been changed over 12 years: olanzapine and risperidone in 2002 and quetiapine, aripiprazole, and olanzapine in 2014 were first-line AAP.

There have been evident preference changes: increased for AAP and lamotrigine and decreased for AD. The high preferences for aripiprazole and lamotrigine in later editions were likely derived from favorable tolerability.

The authors have not supplied their declaration of competing interest.